HCV Treatment Can Avert Transplant Even in Severe Disease

A quarter of patients with decompensated cirrhosis could safely get off waiting list

AMSTERDAM -- Evidence is mounting that curative treatment for hepatitis C (HCV) can help get some patients with advanced cirrhosis off the list for liver transplant, a researcher said here.

In a cohort of 142 patients successfully treated for HCV while waiting for transplant owing to decompensated cirrhosis, more than 25% were able to get off the list, according to Luca Belli, MD, of the Niguarda Hospital in Milan, Italy.

And in those patients, the risk of liver-related complications was very low at least in the early years after starting treatment, Belli reported at the International Liver Congress, the annual meeting of the European Association for the Study of the Liver (EASL).

"So far the risk of dying after de-listing is much lower than that of dying after receiving a liver transplant," Belli said.

That study, of the so-called ELITA cohort, found that about one patient in five could be de-listed owing to clinical improvement after successful treatment with direct-acting agents (DAAs) against HCV.

But the cohort was too small and the follow-up too short to allow investigators to analyze predictors of who could be de-listed or what happens to patients taken off the list, Belli said.

To help fill the gap, Belli and colleagues expanded the treatment cohort from 103 to 142 patients, of whom 38 patients (up from 21) were de-listed on account of clinical improvement. The follow-up time was extended as well, to 28 months from 15.

The investigators used the additional data to examine three primary endpoints: the probability that a patient would get off the list, what factors predicted that outcome, and what happened to patients once they were de-listed.

Overall, they found, just under half of the cohort went on to have a transplant, despite the HCV cure, while just over a quarter -- 26.7% -- were de-listed. The remainder either died or dropped out of the cohort, Belli said.

Belli and colleagues found that many of the aspects of liver disease improved after treatment: among other things, MELD scores went down, Child Pugh scores fell, albumin rose, and the proportion of patients without hepatic encephalopathy approached 100%.

During follow-up after de-listing, two participants re-decompensated and one rejoined the transplant list. A third member of the de-listed group died of hepatocellular carcinoma, but at the end of the study all other members of the group remained alive, Belli said.

Analysis suggested that three factors helped predict who could get off the list: baseline MELD scores (less than 16, 16 through 20, and greater than 20), change in MELD after 12 weeks of therapy, and the presence or absence of hepatic encephalopathy, Belli said.

He cautioned that although there is little evidence so far of liver complications in these patients, "very prolonged follow-up data" is needed to confirm the results.

Curative therapy for HCV has been shown to reduce the consequences of the disease both in the short term and the long term, commented Marco Marzioni, MD of the University Hospital of Ancona, in Italy, and this study extends those findings.

"This study is very important as it shows that HCV therapy may be effective in avoiding or reducing the need of transplantation in a significant number of cases," Marzioni said, adding: "It is an excellent example of the fact that clearing the hepatitis C virus can provide immediate advantages for patients, in addition to the longer term advantages."

The investigators did not report any external support for the study. Belli disclosed relationships with Gilead, Abbvie, BMS, and MSD.

Marzioni said he had no commercial relationships that might be perceived as a conflict.

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